An Atypical Presentation of Varicella Zoster (VZV) Vasculopathy

Background: VZV vasculopathy in immunocompetent or immunocompromised individuals can be unifocal or multifocal involving likely both anterior and posterior circulations in the brain. It can cause ischemic stroke, aneurysm, subarachnoid and intracranial hemorrhages, and carotid dissection in central nervous system (CNS). Case Description: 65 year old female with history of hypertension presents with two days of generalized weakness along with a week of sudden onset severe generalized headache. Upon presentation, she was afebrile, normotensive, non-toxic appearing, and alert and oriented, with 4/5 right sided hemibody weakness and patchy multimodal sensation decrease as well as increased reflexes on the left hemibody. We performed head computerized tomography (CT) which was unremarkable, head and neck CT angiography positive for diffuse narrowing in both anterior and posterior circulations. Her magnetic resonance imaging (MRI) of the brain was positive for bilateral cortical watershed infarcts. The patients’ cerebrospinal fluid results were suggestive of bacterial meningitis, however only VZV PCR was positive. The patient was started on acyclovir iv for 14 days with improvement of her symptoms and imaging findings in 3 months. Discussion: Patients’ non-toxic appearance with no signs of infection might be falsely reassuring for patients presenting with CNS vasculopathy. Our case raises awareness of the need of CSF studies to rule out an underlying infectious etiology in these cases.   Also our case is unique due to VZV meningitis presenting with a CSF profile similar to bacterial meningitis. Patients with intracranial diffuse vasculopathy should be treated empirically until CSF studies have been completed.